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SURVEY PARTICIPANT CONSENT FORM

Study Title:	COVID-19 Public Education Campaign Creative Testing Survey
Telephone:	571-858-3757 (24 hours)

What is the key information?

You are being asked to participate in a research study collecting information about educational messaging related to COVID-19. This form describes the purpose, procedures, benefits, risks, and precautions of the information collection. It also describes your right to withdraw at any time.

This information collection is being done to help refine and enhance public education messaging related to COVID-19 that will eventually be disseminated to the public.

What do I need to know about this study?

If you agree to be part of the research study, you will be asked to participate in a survey where you will answer questions about your perceptions and reactions to messaging related to COVID-19. The survey will last about 20 minutes and you will be video recorded while you watch a 60-second video. You do not have to answer any questions that you do not want to.

What are the potential risks of being in this study?

There are minimal risks associated with this project. There is a possible risk of breach of confidentiality. This risk is minimized by protections described in the “Who will see the results of this project or my information?” section below. Please help protect your privacy and confidentiality by not providing any personally identifiable information in your responses. The study staff will do its due diligence to remove any personally identifying information from the data collected from your survey.

Does participating in this project provide any benefits?

This study is for research purposes only. Although you may not directly benefit from participating in this study, others may benefit because the findings of this study will be used to inform messaging and public education efforts pertaining to COVID-19.

Are there alternatives to participating?

This research study is for research purposes only. The only alternative is to not participate in this study.

Will it cost me anything to participate in the project?

There are no costs to participate in the project. Participants in the survey will receive $1.50 for their participation; you will be paid at the end of your participation in this study.

Do I have to be in this project?

Your participation is voluntary, which means you can stop or withdraw at any time. You may choose to not participate, or you may withdraw from the study for any reason without penalty or loss of benefits to which you are otherwise entitled.

Who will see the results of this project or my information?

Your answers will only be seen by the study staff. We will be very careful to only let people working on the project see your responses. There is minimal risk that others might find out what you respond, despite all of our best efforts. In the case of a breach of confidentiality, appropriate steps will be taken to notify participants.

For a small portion of the survey, your webcam will record your facial responses to creative concepts. Data is saved as a heat map and your actual face is not recorded or saved on file. By signing this form, you consent to using your webcam during this study.

All of the information we collect, including any answers to the survey, information collected during screening, and open-ended answers will be stored on a password-protected computer and/or in locked cabinets that only the project team can access. We will collect some personal information from you, like your age and race, but we will not collect any information that could identify you personally. After three years, all of the collected information will be destroyed by securely shredding documents or permanently deleting electronic information. Results from this project might appear in professional journals or scientific conferences or shared with other project teams. No individual participants will be identified or linked to the results. We will not disclose your identity in any report or presentation.

Whom to contact about this study:

If you have questions, concerns or complaints about the study, please contact the Principal Investigator at the telephone number listed on the first page of this consent document.

An institutional review board (IRB) is an independent committee established to help protect the rights of research subjects. If you have any questions about your rights as a research subject, and/or concerns or complaints regarding this research study, contact:

1. By mail:

Study Subject Adviser BRANY IRB

1981 Marcus Ave, Ste 210

Lake Success, NY 11042

2. or call toll free: 516-470-6900

3. or by email: [email protected]

Although the questionnaire will primarily ask that you provide feedback and input on messages and creative assets, we recognize the topic of COVID-19 may bring up some discomfort. If you need any additional support, please contact one of the following.

Substance Abuse and Mental Health Services Administration (SAMHSA) Disaster Distress Helpline

• Call 1-800-985-5990

• Text TalkWithUs to 66746

Suicide Prevention Lifeline

• Call 1-800-273-8255

• Online chat: https://suicidepreventionlifeline.org/ and click “Chat”

Statement of Consent

Do you consent to participate in this study? By consenting, you agree to participate and that you have read, understood, and had time to consider all of the information above.

Yes, I agree to participate.

 No, I do not agree to participate in this project.